To whatever variety it belongs, the tumor may be at times observed to vary in size, quite independently of its natural growth. This change of volume takes place most frequently before or during menstruation. It may be due to increased fullness of the vessels, but more frequently, since these growths are but slightly vascular, is owing to increased suc culence dependent upon menstrual congestion. In certain soft intra muscular tumors, a diminution of size may occur through a contraction of the remaining muscular elements, a return to the former dimensions depending upon subsequent relaxation of the muscular tissues. (Vir chow, lilebs.) The sub-serous fibroids are attached to the external uterine wall by a pedicle of varying thickness and length. The longer and thinner the pedicle, the more movable is the tumor in the peritoneal cavity. In the case of a large tumor with short pedicle, the uterus is often pulled up for some distance and its cavity deepened very considerably, while the tumor itself may extend up as high as the epigastrium. In such cases it may be impossible to reach the os with the finger introduced into the vagina. Spencer Wells' observed a very large fibromyoma of this sort, extending from the posterior uterine wall, which he mistook for an ovarian tumor, and removed. This drawing up of the uterus may reach such a degree as to tear the body completely away from the cervix.' Times' relates a case in which the uterine cavity was six inches deep, and the cervix was so stretched that its canal was obliterated an inch from the os. A space of two inches between the cervical canal and the cavity of the body was occupied by a thin muscular cord, in which the obliterated canal could be traced. This case, however, cannot strictly be regarded as a separation of the neck from the body of the womb. (See also Buster's case, p. 174.) Rokitansky by no means relates a case of this kind, as has been repeatedly attributed to him, but merely says that "a separation of the body from the cervix " might occur.
The shorter the pellicle is, the less distinctly can we determine an inde pendent movement of the tumors. When, as is most frequently the case, they spring from the posterior wall of the uterus, they may sink down into Douglas's cul-de-sac and become immovably wedged there. Adhesions often form in these cases between the tumor and the peritoneum, so that the former is actually immovable. In other cases, in which there are no ad hesions, the immobility is only apparent; and firm pressure through the vagina may force the growth out of the pelvis into the abdominal cavity ,(provided the pedicle be long enough), thus often relieving grave symp toms of strangulation. These lodgments take place most frequently in the case of a tumor with a long pedicle, which allows the growth to obey the laws of gravity and to sink into the pelvis. So that when we find a tumor with considerable mobility in the abdominal cavity, provided it be not of great size, we may conclude that it has a rather short attach ment. The greater or less mobility of these new growths often occa sions a number of the most varying symptoms, which will be considered later. But it seems also as though a slight degree of local peritonitis, lead ing to adhesions between the tumor and neighboring organs, were easily caused thereby. Thus adhesions of sub-serous fibroids with the anterior
abdominal wall and the mass of the intestines are sometimes seen, which give rise to the most painful symptoms. The adhesions to neighboring organs may lead to an increased growth of the tumor, owing to the com munications established with the vessels of the omentum, etc. (Virchow. See also the cases observed by Hofmeier at Schrbder's clinic.') Ab scesses of considerable size even may grow into the tumor from the point of adhesion. (Chambers,' Vogel, Rokitansky, and Virchow, loc. cit.) The adhesions may even so surround the tumor as to cause an apparent or real separation from the uterus itself. (Rokitansky, Virchow.) The tumor may become adherent to a movable organ, as the intestine, or to one whose form is changeable, as the bladder. In such case, provided the pedicle be long and thin, the tumor will follow the movements of the organ to which it is attached, and appear to lie free in the abdominal cavity. When the tumor is attached to the wall of the pelvis, the enlarge ment of the uterus during pregnancy may cause a tearing loose of the new growth. This was the mode of production of the pelvic tumors de scribed by Huguier and IST6laton.' Depaul ' found a fibroid tumor lying detached from the uterus in Douglas's Turner' found a cal cified fibroma, the size of a hazel-nut in Douglas's pouch, which was at tached to none of the neighboring parts. In the same case a second smaller tumor was found separated from the uterus, but attached to the pelvic wall behind this organ. A third tumor, the size of a walnut and calcified, was discovered firmly united to the bladder and wall of the pel vis, while it was still connected with the uterus by a thin pedicle.
Simpson ' states that he has met with several such cases. He relates especially the case of a lady, the subject of extra-uterine pregnancy, after whose death, consequent upon puerperal peritonitis, a fibroma was found attached firmly to the anterior abdominal wall, the pedicle of which, lead ing to the uterus, had been torn by the growth of the latter organ. West ° and have also seen cases of this kind.
The pedicle of such a tumor is usually very thin and contains a scanty supply of blood-vessels, so that the fibroma often atrophies or becomes calcified, and is seen as a little shrivelled-up mass. In other cases, where the tumors are bulky, the pedicle may contain very large vessels. Cham bers (I. c., p. 33) saw several vessels the size of a quill in such a pedicle, and Graily Hewitt ° mentions some one-third of an inch in diameter. Martin le Jenne' found a tumor weighing six pounds attached to the uterus by a pedicle two inches in length and one inch in thickness. Cruveilliier describes the pedicle of a twelve-pound myoma with the thickness of a quill pen. James Cappie " found in a woman suffering from a fibroid tumor of the uterus, who died from peritonitis consequent upon a fall, that the tumor, measuring twenty-four inches in circumference, was par tially gangrenous. This had been caused by a twisting of the pedicle one and a half times around its axis, thus stopping the blood supply to the tumor.